The Who, What and Why Behind Her Treatment

I thought it was high time to introduce you to the directors of this production I’ve been starring in, the adorable and delightful total geniuses who are saving my life: Dr. Melvin Silverstein, surgical oncologist, and Dr. James Waisman, medical oncologist. I wanted to chat about some of the decisions behind the big fun they’ve been putting me through for the last eight months.

Unfortunately, Dr. Waisman couldn’t join us, but here is Dr. Silverstein, who founded the Breast Center in Van Nuys (where I’m being treated) in 1979 and in September will go to USC’s Norris Cancer Center, as professor of surgery and to direct the breast center there.

Mary Susan Herczog: So what, exactly, was my diagnosis?

Melvin Silverstein: “Diagnosis” is a broad term. If there are a bunch of people in a room, we can divide them into short and tall, or men and women, but that doesn’t tell you very much. Breast cancer can be divided into invasive and noninvasive cancer. Invasive, which you have, is divided into ductal and lobular. You had ductal cancer, which begins in the ducts that connects the lobules, which make the milk, to the nipples.

MSH: What stage was it? For that matter, what do the stages mean?

MS: You had Stage 3A. There are five stages–O, 1, 2, 3, 4. Stages 2 and 3 also have A and B, which indicate how far the cancer has spread. Zero is noninvasive; 1, 2, 3 and 4 are invasive. As the numbers [or letters] go up, the prognosis gets worse. You would like to have lowest number you can.

MSH: So how bad is Stage 3A? You can tell me, now.

MS: There is local, regional and systemic disease. Local is a fire in your house. Regional is out in your backyard and systemic is the whole neighborhood. If you have a Stage 1 tumor, it’s localized and just in the breast. Stage 3 means there are more locally advanced signs, and therefore there is an increased probability it’s somewhere else. Stage 4 means we’ve proven it’s somewhere else: liver, lung, brain, bone. Positive lymph nodes [which Herczog had] are not “somewhere else”–that’s regional involvement.

There are people with local disease who die of breast cancer, and there are those with really bad disease who don’t. The reason is a whole lot of things we really don’t understand. That’s really what keeps us coming back and what’s so interesting about this. We are always looking for the clues. Why do some people with more advanced cancer still make it? Is there something we can copy and give to someone else?

MSH: You treated my tumor, instead of performing a mastectomy, with a lumpectomy and radiation therapy, which saved my breast–thanks for that, by the way. That’s still a relatively new method of dealing with it. Wasn’t the Breast Center among the first to try it?

MS: We were just about the first in L.A. The Breast Center started in 1979, and I don’t think [the procedure] really became popular or accepted until 1985. So we were ahead of our time doing that. There were people doing it, but the first prospective randomized study wasn’t published until 1981. In 1979, it was experimental. But we always had avant-garde patients who would read about things and say “Can we do this?”

MSH: But I’ve heard the majority are still performing mastectomies.

MS: When you look at the analysis across the U.S., it seems to be regional–pockets where [lumpectomy and radiation] is used a lot, but places where it’s not done at all. There are clear-cut biases against it and for it all over the place. It looks like it’s being used less frequently than it could be.

MSH: So how often does the Breast Center choose this method?

MS: Literally as much as we can. It takes two to make a marriage, so to speak. For us to do it, the patient has to want to do it, and she has to be a candidate for it. We made you a candidate by giving you the [chemotherapy] first. When we first saw you, your lesion was probably too big and your breast too small. If we took a 5-centimeter tumor out, plus a centimeter all around, there was a good chance we weren’t going to get acceptable cosmetic results or good margins [cancer-free tissue surrounding the area where the tumor was removed]. If we couldn’t, then we would tell you you needed a mastectomy. So we shrank the tumor, and we did get acceptable margins and good cosmetic results. That only happens in these modern times. It wouldn’t have happened in the 1980s.

MSH: Is that a new wrinkle, shrinking the tumor with chemo first?

MS: It is. There has only been one really good prospective study on this. Here’s the truth. We were hoping that if we gave the drugs first, we would cure more patients and improve survival. What it proved is, if you gave the drugs first, more [patients] got breast preservation.

With so many women, boom–biopsy and mastectomy and that’s it. If there is one thing we should do now, we should be educating each other. For example, the state of the art right now is getting a biopsy with a needle instead of in the operating room; this saves you time and money, and doesn’t scar. If your doctor can’t get a biopsy with a needle, then he should send you to someone who can. The key for women is, No. 1, get a mammogram. Then if you see something abnormal, get a biopsy with a needle. Then depending on the results, talk to everyone up front and make a master plan and coordinate. Can we go the breast-saving route?

MSH: You told me once the priorities, in order, were cure, save breast and then cosmetic results.

MS: The first goal is the absolute highest probability of survival. “Save breast” and “cosmetic” are essentially the same thing. If the result is a horribly distorted breast, you are better off with mastectomy and reconstruction. But in general, a well-preserved breast is always better than a mastectomy.

MSH: Are there statistics on how successful the lumpectomy and radiation method is?

MS: There are two types of recurrence–local and distance. If someone does a mastectomy, there is very little chance of local recurrence, about 1% to 3%. If you save the breast, the recurrence rate is at least 10% over 10 to 20 years, maybe 15% depending on other factors. If you save the breast, the cancer could come back. However, a local recurrence, according to most studies, has very little impact on living or dying. [Choosing the lumpectomy] means 90% of women who do this live their whole life with that breast. In my opinion, that’s worth doing.

MSH: One of the backhanded benefits of breast cancer is that, unlike in the rest of my life, in this area, at age 34–33 when diagnosed–I’m still considered a very young woman.

MS: You are very young. The average [patient] is in her mid-50s. There really is no [recommended] breast screening for women under 40, and many women wait until they are 50. Also, mammograms for young women are harder to read, and younger women on the average are diagnosed later than older women. That’s why we so desperately need blood tests, like the PSA for men with prostate.

MSH: I’ve been lecturing friends and total strangers nonstop about doing breast self-exams and getting regular mammograms. Could you reemphasize why this is so important?

MS: If you find a small tumor, 10 millimeters or smaller, many published studies say the cure rate is about 90% at 10 years. For a noninvasive tumor, the cure rate is almost 100%. That is the benefit of mammograms.